Knowledge, Awareness, and Attitudes Toward Organ Donation Among Ugandan Healthcare Students: A Cross-Sectional Study.

Non-communicable diseases (NCDs) continue to pose a major challenge to global health, accounting for approximately 41 million deaths each year and representing 74% of all mortality worldwide [1]. This burden is especially significant in low- and middle-income countries like Uganda, where conditions such as chronic kidney disease are increasingly prevalent due to poorly controlled hypertension and diabetes [2,3]. For patients with end-stage organ failure, organ transplantation offers a vital, life-saving treatment and a chance to improve quality of life [4].

Despite the clear benefits of transplantation, access to donor organs remains a major barrier globally, with more than 90% of transplant needs unmet [5]. In Uganda, efforts to establish a functional organ transplantation program have gained momentum following the recent enactment of the Human Organ Donation and Transplant Act, 2023, and the country’s first successful kidney transplant at Mulago National Referral Hospital [6-8]. However, the success of any transplantation program is dependent on an adequate supply of donor organs and public willingness to participate in donation programs.

Healthcare professionals play a critical role in promoting organ donation through patient education, advocacy, and community engagement. As future physicians and health system leaders, healthcare students are uniquely positioned to shape public attitudes, and their level of knowledge and attitudes will influence not only future clinical practice but also public trust and community participation in organ donation programmes [9,10].

Previous studies in various countries have shown varying levels of knowledge and mixed attitudes toward organ donation among healthcare students, influenced by factors such as cultural beliefs, religious views, family opinions, and gaps in medical curricula [11]. However, in Uganda, there is limited published data specifically examining healthcare students’ knowledge and attitudes toward organ donation, even as the country takes significant steps to scale up its transplantation services [7].

In Uganda, formal undergraduate teaching on organ donation and transplantation is limited and inconsistently integrated into medical and allied health curricula. Assessing healthcare students’ knowledge and attitudes toward organ donation is therefore essential for identifying gaps that may hinder effective education and advocacy efforts. This information can inform curriculum improvements and targeted sensitisation strategies to prepare future healthcare professionals to champion organ donation and transplantation in Uganda. This study thus aims to evaluate the current levels of knowledge, awareness, and attitudes regarding organ donation among Ugandan healthcare students.

Study Design and Setting

A cross-sectional study was conducted between January 2025 and April 2025 among undergraduate healthcare students enrolled in ten medical schools across Uganda. The selected universities included a mix of public (Makerere University, Mbarara University of Science and Technology, Gulu University, Busitema University, Kabale University, Soroti University) and private institutions (Kampala International University, Islamic University in Uganda, King Caesar International University, Uganda Christian University). This diversity was purposively sought to ensure a comprehensive representation of Uganda’s future healthcare workforce.

Study Population

The target population was students pursuing Bachelor’s degrees in Medicine and Surgery (MBChB), Nursing, Dentistry, or Pharmacy. Participants were required to provide informed consent. Students with a personal or family history of organ donation were excluded to minimise potential bias in knowledge or attitude levels. This was assessed through a screening question in the questionnaire, and respondents who indicated such a history were excluded during data cleaning.

Sample Size and Sampling Technique

A minimum sample size of 384 students was calculated using the Kish and Leslie formula for a single population proportion, assuming a 50% expected proportion to maximise sample size, with a 5% margin of error and a 95% confidence level. The study was not powered to detect discipline-specific subgroup differences. A hybrid sampling strategy was employed. Purposive sampling was used at the institutional level to select the ten universities. Within these universities, convenience sampling was used to recruit participants. The survey link was disseminated through existing WhatsApp groups managed by class representative data collectors to ensure reach across different academic years and programmes.

Data Collection Tool

The questionnaire was adapted from previously published organ donation knowledge and attitude surveys conducted among medical and healthcare students in Ethiopia, Uganda, and Brazil [9, 12-14]. Relevant items were drawn from Dibaba et al., Kituuka et al., Bongomin et al., and Miranda et al. The instrument was modified to reflect the Ugandan medical education, healthcare, and regulatory context. To enhance contextual relevance and content validity, the adapted questionnaire was reviewed by senior clinicians and academic faculty with experience in transplantation and medical education. It was subsequently pilot-tested among diploma nursing students to assess clarity, comprehension, and appropriateness of wording, and minor revisions were made based on feedback. Pilot participants were not included in the final analysis. Because the survey link was disseminated through multiple WhatsApp groups without a defined sampling frame, the total number of students who received the link could not be determined; therefore, a response rate could not be calculated.

The final questionnaire consisted of three sections:

1. Socio-demographic data: age, sex, university, programme, year of study,  and religion.
2. Knowledge assessment: 15 multiple-choice and true/false items assessing general concepts, eligible organs, and the legal and procedural framework for organ donation in Uganda.
3. Attitude assessment: 10 items measured on a 5-point Likert scale (“Strongly Disagree” to “Strongly Agree”) exploring views on organ donation and transplantation.

Data Analysis

Data were exported to SPSS version 20 for analysis. Descriptive statistics including frequencies, percentages, means, and standard deviations were used to summarise participants’ demographic characteristics, knowledge scores, and attitude responses.

Knowledge was assessed using 15 questions, with one point awarded for each correct response (maximum score = 15). In the absence of an established or locally agreed competency benchmark for organ donation knowledge among healthcare students in Uganda, the median score was used solely to describe relative knowledge levels within the cohort rather than to define adequacy or competence. Knowledge scores were analysed as continuous variables and additionally categorised using the median score (8) to compare relative knowledge levels within the cohort (≥8 vs ≤7). Attitudes, measured on a 5-point Likert scale, were summarised using mean scores, with higher scores indicating more favourable attitudes toward organ donation.

Bivariate analyses were conducted using chi-square tests to assess associations between the median-based knowledge categories (higher vs. lower knowledge scores) and demographic variables. Variables with a p-value ≤0.20 at bivariate analysis were considered for inclusion in multivariable logistic regression models. Odds ratios (ORs) with 95% confidence intervals (CIs) were estimated using logistic regression to quantify the strength of these associations. A p-value <0.05 was considered statistically significant.

Ethical Considerations

Ethical approval was obtained from the Gulu University Research Ethics Committee (GUREC-2024-093) and registered with the Uganda National Council for Science and Technology. Participation was voluntary, and informed consent was obtained electronically prior to survey completion. No personally identifying information was collected, and all data were kept confidential and reported in aggregate form.

Demographic Characteristics of Participants

A total of 400 healthcare students from ten Ugandan universities participated in the study. The cohort’s mean age was 25.4 years (±4.2), with a male-to-female ratio of approximately 2:1 (68.0% vs 32.0%). The majority (79.8%) were pursuing an MBChB degree, while the remainder were enrolled in Nursing (12.5%), Pharmacy (5.8%), Dentistry (1.0%), and other programmes (0.9%). Participants were distributed across all academic years, with most in their fourth (31.5%) and fifth (29.5%) years. The religious composition was diverse, primarily Catholic (33.8%) and Protestant (33.5%). A full breakdown is presented in Table 1.

Knowledge Regarding Organ Donation

Out of 400 participants, 356 (89.0%) reported having heard about organ donation in the last 12 months. The mean knowledge score was 6.62 (±1.91 SD) out of 15. Twenty percent scored fewer than five correct answers, including one student with no correct responses. A total of 66.5% of participants had lower knowledge scores (≤7) (Figure 1).

As detailed in Table 2, knowledge was highest for items concerning the irreversibility of brain death (86.3% correct) and the possibility of multi-organ donation after brain death (78.8%). Knowledge was lowest on items related to the legal framework for organ distribution (23.0% correct), the identification of all eligible organs and tissues (6.2% correct), and the clinical criteria for diagnosing brain death, such as the role of a neurologist (9.3% correct) and the apnoea test (30.3% correct). Only 182 (45.5%) knew that brain death should be reported to the Organ Notification, Procurement, and Distribution Center (CNCDO), 137 (34.3%) identified the hospital donation committee as the family interviewer, and 256 (64.0%) knew that informed family consent is required before organ removal after brain death.

Factors Associated With Knowledge

No statistically significant associations were found between knowledge category and any demographic variable, including sex, programme of study, year of study, religion, or age group (all p > 0.05). Several descriptive patterns were observed across subgroups. Students enrolled in programmes other than Medicine (including Nursing, Dentistry, and Pharmacy) had a lower proportion of higher knowledge scores (28.4%) compared with medical students (34.8%); however, this difference was not statistically significant (p = 0.091). Variation was also noted across academic years, with lower proportions of higher knowledge scores among second-year students (13.6%) and higher proportions among fifth-year (40.6%) and sixth-year students (50.0%). Across age categories, students aged 24–26 years showed the highest proportion of higher knowledge scores (42.0%), while those aged ≥27 years showed the lowest (26.6%). Full bivariate results are presented in Table 3.

Attitudes Toward Organ Donation and Receipt

Attitudes toward organ donation were overwhelmingly positive at a systemic and altruistic level. Most students (97.2%) agreed that organ donation helps save lives, and 96.5% supported a national policy to govern the practice. Similarly, 96.5% believed the government should allocate funds to organ donation programmes. However, personal commitment was lower: while 82.3% would encourage someone else to donate, only 58.2% agreed or strongly agreed that they would personally donate their own organs, with 35.5% undecided.

Attitudes toward receiving a transplant were more favourable than those toward donating. A high percentage (84.8%) would accept an organ if needed, and 92.7% would encourage someone else to do so. Support for national development was also high: 95.2% supported introducing transplantation services, and 97.7% endorsed allocating funds for this purpose. Tables 4 and 5 summarise attitudes toward organ donation and receipt.

Sources of Information

As elaborated in Figure 2, the majority of participants accessed information about organ donation from medical workers (n = 216), followed by social media (n = 209), and minimally from parents or relatives (n = 10).

This study assessed knowledge, awareness, and attitudes toward organ donation among Ugandan healthcare students at a time when Uganda is moving from policy intent to early implementation of transplantation services. Although awareness was high (nearly 9 in 10 students), knowledge scores were low overall, with gaps concentrated in domains that determine whether donation systems function safely and credibly, namely legal processes, governance structures, and clinical determination of brain death. These findings matter because healthcare students are the future workforce for counselling families, reinforcing public trust, and supporting referral and notification pathways within Uganda’s new regulatory environment [8,12].

Only one-third of participants demonstrated higher relative knowledge scores. A similar proportion has been reported among Omani university students, though that study used a predefined threshold of ≥ 60 rather than a median-based categorisation [15]. Despite methodological differences, both studies demonstrate substantial gaps in operational understanding. In Uganda, this distinction is particularly important because the country has recently enacted legal reforms and initiated transplantation services, which require a workforce that can translate policy into practice [7,8,12].

Several knowledge gaps have direct implications for implementation. The very low ability to identify eligible organs and tissues indicates incomplete understanding of what donation entails, limiting students’ readiness to communicate accurately with patients and families. Similar challenges have been reported among trainees in India and Brazil, particularly for less commonly discussed organs [16–18]. Knowledge related to deceased donation pathways, institutional roles, and brain death determination was also limited, mirroring findings from Oman, Turkey, South Africa, and Saudi Arabia [15,19–21]. Although most participants recognised brain death as irreversible, uncertainty around practical criteria such as the apnoea test may hinder timely identification and consideration for deceased donation. In contrast, higher baseline understanding has been reported among Canadian students, likely reflecting greater curricular exposure [22].

We did not identify statistically significant demographic predictors of higher knowledge scores, although descriptive trends across year of study were observed (highest in final year students but lowest in second year students). This may reflect limited subgroup power or inconsistent exposure to organ donation content across training programs. In Ethiopia, Dibaba et al. reported significant associations with year of study and sex, indicating that context and training pathways may influence who gains knowledge and when [9]. From a program perspective, the key message is that knowledge gaps are not confined to a single subgroup, which supports broad-based rather than targeted-only interventions.

Attitudes toward organ donation were highly favourable at the policy level, with strong support for national regulation and government funding. This aligns with findings from Uganda’s general population and international studies where endorsement of system development is often high even when personal willingness is lower [12,27-29]. This matters because it suggests acceptability for building national systems, but also signals that implementation strategies must go beyond policy endorsement to address the barriers that shape personal decision-making.

Personal attitudes towards willingness to donate were lower and a large proportion remained undecided.  This has been well documented in studies other from Nigeria and India, where high awareness and systemic support did not translate into personal willingness. The reasons are multifactorial and may include knowledge deficits, cultural and religious beliefs about bodily integrity, and mistrust of the health system or uncertainty about legal safeguards [28,29]. In early donation systems, hesitancy may be driven less by opposition to the concept and more by uncertainty about fairness, safety, and safeguards, especially in settings where organ trafficking concerns are salient and trust in institutions varies [8,12]. This interpretation fits with the broader global surgery emphasis on trust, accountability, and governance as determinants of service uptake, not only clinical capacity.

A donor–recipient asymmetry was also observed, with greater willingness to receive than to donate. Similar patterns have been reported in China and other settings [31-33]. This imbalance is relevant because transplantation systems depend on reciprocity and shared social commitment; if future clinicians primarily see transplantation through the lens of receipt rather than donation, advocacy efforts may remain weak even when attitudes appear positive. Findings from high-income settings also show a recurring pattern of favourable attitudes despite knowledge gaps, reinforcing the need for structured training rather than assuming familiarity. In Finland, willingness to donate after death was high among university students, yet only a minority reported receiving education on organ donation during their studies and there were gaps in acceptance/understanding of brain death [42]. Similarly, a Canadian survey of undergraduate medical students reported strong support for organ donation and for formal education on the topic, while identifying training needs and variable knowledge [22]. In the United States, surveys suggest that clinician and trainee attitudes can differ from the general public, highlighting why medical education and clinician engagement remain central to improving donation systems [43].

Information sources offer a practical entry point for intervention. Social media, lectures, and peers were major sources of information, consistent with studies in India, Saudi Arabia, and Nigeria [15,29, 34-35]. Social media’s prominence presents both an opportunity and a risk: it can rapidly extend reach, but may also amplify misinformation, particularly where structured public education is limited [36,37]. From a program standpoint, this supports pairing formal institutional messaging with youth-facing digital strategies, rather than treating public education and medical training as separate lanes.

Finally, the role of transplantation in LMIC priority-setting deserves explicit consideration. While transplantation requires sustained follow-up and immunosuppression and can strain constrained systems, emerging evidence indicates kidney transplantation can be cost-effective relative to long-term dialysis in many contexts [44,45]. In Uganda, strengthening organ donation knowledge among the future workforce is therefore not only an educational concern; it is part of building a system that is ethically governed, clinically safe, and publicly trusted as transplantation services expand.

This study demonstrates that while awareness of organ donation among Ugandan healthcare students is high, detailed knowledge and personal attitudes toward donation remain limited. Students express strong systemic and ethical support for organ donation programs but are less confident or positive about personal involvement, particularly as potential donors. Addressing these gaps through curriculum reform, targeted educational interventions, and nationwide sensitization will be key to nurturing informed, confident, and proactive advocates for organ donation. As Uganda’s transplant program continues to develop, empowering healthcare students, the future frontline of the health system, will be central to ensuring its long-term success and sustainability.